Herpes Simplex Virus—Genital Herpes
Cheryl A. Glass and Leslie B. Norman
Definition
A.Herpes simplex is a chronic lifelong viral infection that is transmitted by direct contact with the secretions or mucosa of an infected individual who is shedding the virus. The virus is usually characterized by painful vesicular lesions that form an ulcer, crust over, then dry and resolve (without scarring) within 2 to 3 weeks. There are two types of the herpes virus. Herpes simplex virus type 1 (HSV-1) is oral herpes and type 2 (HSV-2) is genital herpes. HSV-1 can result in cold sores or fever blisters around the mouth. Oral herpes can spread from the mouth to the genitals through oral sex and cause genital outbreaks. Genital ulcerative disease is also transmitted through vaginal sex and anal sex with a partner that has the disease. Many infected individuals are not aware of their status and can transmit the virus when asymptomatic.
B.Herpes infection can cause sores or breaks in the skin or lining of the mouth, vagina, and rectum providing a way for exposure to the HIV virus. A person infected with both HIV and genital herpes increases the chance that HIV will spread to an HIV-uninfected sexual partner during contact with their mouth, vagina, or rectum.
C.The Centers for Disease Control and Prevention (CDC) does not recommend screening for HSV-1 or HSV-2 in the general population.
D.Herpes is not a notifiable disease to the state or local health departments. Public health surveillance for herpes infections is mainly done through population-based, national surveys, such as the National Health and Nutrition Examination Survey (NHANES).
E.Both laboratory-based assays and point-of-care testing that provide results for HSV-2 antibodies from capillary blood or serum during a clinic visit are available.
Incidence
A.It is estimated that 85% of adults have had oral sex. More than one of every six people aged 14 to 49 years in The United States have genital herpes.
B.The risk for neonatal transmission from an infected mother is 30% to 50% among women who acquire genital herpes near the time of delivery and low (<1%) among women with prenatal histories of recurrent herpes or who acquire genital HSV during the first half of pregnancy.
Pathogenesis
A.HSV is the causative organism. HSV-1 typically produces oral lesions, and HSV-2 most commonly causes genital lesions. However, HSV-1 can cause genital outbreaks as well as oral. HSV-2 is passed in saliva with oral herpes infection; genital secretions, vaginal delivery, and autoinoculation are all possible routes of transmission.
B.The virus remains dormant, and outbreaks can be stimulated by several factors, including stress, illness, sunlight exposure, and menstruation. A prior infection with HSV-1 can increase the incidence of an asymptomatic HSV-2 infection by threefold.
C.Failure to detect HSV by culture or PCR, especially in the absence of active lesions, does not indicate an absence of HSV infection because viral shedding is intermittent.
Predisposing Factors
A.Early age at first coitus.
B.Multiple sexual partners.
C.History of sexually transmitted infections (STIs).
D.Men having sex with men (MSM).
Common Complaints
A.Dysuria.
B.Pruritus.
C.Burning.
D.Swelling sensation.
Other Signs and Symptoms
A.Primary episode:
1.Painful, vesicular, ulcerated, or crusted oral or genital lesion, singly or in clusters.
2.Flu-like syndrome: Fever, chills, headache, malaise, and myalgia.
B.Recurrent episode:
1.Less painful lesions and little or no systemic symptoms.
2.Prodromal symptoms prior to an outbreak described a localized genital pain, tingling or shooting pains in the legs, hips, or buttocks that occur hours to days before the eruption of the herpetic lesions.
Subjective Data
A.Elicit history of onset of symptoms; their location, frequency, and duration; aggravating and alleviating factors; and associated symptomatology.
B.Question the patient about the history of other STIs and sexual habits (oral, vaginal, and anal).
C.Has the patient ever had cold sores?
D.Does their sexual partner have any symptoms or sores?
Physical Examination
A.Check temperature (if indicated).
B.Inspect:
1.Assess all mucus membranes including eyes, nose, mouth, throat, perineum, vagina, penis, and anogenital areas for blister-like, vesicular lesions.
C.Palpate:
1.Check the neck lymphadenopathy.
2.Assess for inguinal lymphadenopathy.
Diagnostic Tests
A.Viral cell culture and PCR are the preferred tests though the sensitivity of the viral culture is low and declines as lesions heal. The sensitivity of viral culture is low for recurrent lesions.
Clinical diagnosis is often reliable, but confirmation with viral culture should be attempted. Vesicles should be unroofed or crust removed for the most reliable sample.
1.Viral isolation: Obtain vesicular fluid by swabbing lesion with cotton- or Dacron-tipped applicator.
2.Place applicator in appropriate transport viral medium before drying.
3.Refrigerate until ready for transport.
B.Serology: Nucleic acid amplification methods, including PCR assays for HSV DNA, are more sensitive. HSV-specific glycoprotein G2 (HSV-2) and glycoprotein G1 (HSV-1) tests vary in sensitivity and false-negative results may occur in early stages of infection so repeat testing may be necessary.
PCR is the test of choice for diagnosing HSV ocular infections and infections affecting the central nervous system and systemic infections (e.g., meningitis, encephalitis, and neonatal herpes). Many infected individuals are not aware of their status and can transmit the virus when asymptomatic. PCR can be used to detect asymptomatic viral shedding.
C.Pap smear is not a sensitive test for HSV-2.
D.Persons with genital herpes should also be tested for HIV.
E.A punch biopsy provides more reliable material for histological examination, particularly when lesions are infected with bacteria and fungi.
Differential Diagnoses
A.HSV.
B.Primary syphilis.
C.Chancroid.
D.Lymphogranuloma venereum.
E.Folliculitis.
F.Candidal fissure.
G.Vestibular vulvitis.
H.Mucocutaneous manifestations of Crohn’s disease.
I.Behcet syndrome.
J.Hand-foot-and-mouth disease (HFMD).
Plan
A.General interventions.
For episodic treatment, the patient should be provided with a supply of drug or a prescription for medication with instructions to initiate treatment immediately when symptoms begin.
B. 
See Section III: Patient Teaching Guide Herpes Simplex Virus
:
1.Counseling of infected persons and their sex partners is critical to the management of genital herpes. The goals of counseling include helping patients cope with the infections and preventing sexual and perinatal transmission:
a.Advise patients to abstain from sexual activity during prodrome or while lesions are present.
b.Condom use should be encouraged when sexually active.
C.Pharmaceutical therapy.
Systemic antiviral drugs can partially control the signs and symptoms of genital herpes when used to treat the first clinical and recurrent episodes or when used as daily suppressive therapy. Newly acquired genital herpes can cause prolonged clinical illness with severe genital ulcerations and neurologic involvement. Even persons with first-episode herpes who have mild clinical manifestations initially can develop severe or prolonged symptoms. Therefore, the CDC recommends all patients with first episodes of genital herpes should receive antiviral therapy.
1.Primary first clinical episode:
a.Acyclovir 200 mg by mouth five times a day for 7 to 10 days or until clinical resolution OR
b.Acyclovir 400 mg by mouth three times a day for 7 to 10 days or until clinical resolution OR
c.Famciclovir 250 mg by mouth three times a day for 7 to 10 days or until clinical resolution OR
d.Valacyclovir 1 g by mouth twice a day for 7 to 10 days or until clinical resolution.
2.Episodic therapy for recurrent genital herpes: Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome that precedes some outbreaks:
a.Acyclovir 400 mg by mouth three times a day for 5 days OR
b.Acyclovir 800 mg by mouth twice a day for 5 days OR
c.Acyclovir 800 mg by mouth three times a day for 2 days OR
d.Famciclovir 125 mg by mouth two times a day for 5 days OR
e.Famciclovir 1 g by mouth two times a day for 1 day OR
f.Famciclovir 500 mg once, followed by 250 mg two times a day for 2 days OR
g.Valacyclovir 500 mg by mouth two times a day for 3 days OR
h.Valacyclovir 1 g by mouth once daily for 5 days.
3.Suppressive therapy for recurrent genital herpes:
a.Acyclovir 400 mg by mouth twice daily, or famciclovir 250 mg by mouth twice a day, or valacyclovir 500 mg by mouth once a day or 1 g by mouth once a day
b.Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in persons who have very frequent recurrences (i.e., >10 episodes per year).
c.Periodically during suppressive treatment (e.g., once a year), providers should discuss the need to continue therapy. Neither treatment discontinuation nor laboratory monitoring in a healthy person is necessary.
Patients receiving daily suppressive therapy of acyclovir 200 mg should use the lowest dose that provides relief from symptoms. Suppressive therapy has been shown to reduce frequency of recurrences by 70% to 80% in patients with more than six recurrences per year. It does not eliminate symptomatic or asymptomatic viral shedding or the potential for transmission. Suppressive treatment with valacyclovir 500 mg daily reduces the rate of transmission to an unaffected partner in discordant, heterosexual partners.
D.Renal dosing for suppressive therapy is required after dialysis.
E.Topical acyclovir, famciclovir (Famvir), and valacyclovir (Valtrex) have had mixed results in clinical trials and are not currently recommended by the CDC.
Emergency Issues/Instructions
A.Intravenous (IV) acyclovir therapy should be provided for patients who have severe HSV disease or complications that necessitate hospitalization (e.g., disseminated infection, pneumonitis, or hepatitis) or central nervous system (CNS) complications (e.g., meningoencephalitis).
Follow-Up
A.Follow-up is not recommended unless it is warranted by clinical presentation.
Consultation/Referral
A.Consultation with a dermatologist may be beneficial in cases of atypical lesions.
B.Consult or refer the patient to a physician when there is prolonged ulceration unresponsive to therapy.
Individual Considerations
A.Pregnancy:
1.Acyclovir and valacyclovir are category B for pregnancy and considered safe to use during pregnancy. These medications can be used for treatment as well as for suppression during pregnancy. The American College of Obstetricians and Gynecologists recommends that suppressive therapy begin at approximately 36 weeks gestation to prevent an outbreak of lesions and to increase the chance of having a vaginal delivery (see Table 18.1).
2.Culture lesions if outbreak occurs. Lesion must be crusted for 7 days for vaginal delivery to be an option; otherwise, a cesarean delivery is recommended to avoid transmission of virus to newborn.
3.Pregnant women without genital herpes should be advised to avoid intercourse during the third trimester with partners known or suspected of having genital herpes.
4.Acyclovir allergy: No effective alternatives to acyclovir have been identified.
B.Partners: Symptomatic partners should be evaluated and treated in the same manner as any patient with genital lesions.
C.Geriatric:
1.Recurrent infection of the buttocks region is not uncommon, especially in females.
2.Medicare offers free STI screening and treatment for seniors.
3.Clinicians need to address the STI issue by including questions about sexual activity in their senior patient assessment.
4.Seniors are at increased risk for STIs due to a weaker immune system and hormone changes.